For the first time in over a decade, there is a growing consensus that America's health care system needs speedy and significant structural reform in order to remain viable. And with the advent of the November presidential election, the issue is back on the table for discussion.
In an effort to look more closely at the direction this policy debate might take, Neurology Today surveyed the public positions of presumptive presidential nominees Republican Senator John McCain of Arizona and Democrat Senator Barack Obama of Illinois.
THE DEMOCRATIC POSITION
“We have reached a point in this country where the rising cost of health care has put too many families and businesses on a collision course with financial ruin and left too many without coverage at all; a course that Democrats and Republicans, small business owners and CEOs have all come to agree is not sustainable or acceptable any longer,” Sen. Obama said in a health-care speech at the University of Ohio in May last year.
Among his plans for fixing the system, Sen. Obama's campaign has said he would expand existing public programs. He would encourage the adoption of electronic medical records via a $10 billion investment over the next five years to help physicians implement new systems, and improve prevention and management of chronic conditions by requiring that plans participating in the public plan implement proven disease management programs.
He also supports the establishment of an independent institute on comparative effectiveness to help physicians compare the best interventions and financially reward improved provider performance, particularly in chronic care and disease management.
Sen. Obama would expand funding for the public health workforce and require providers to report quality and pricing information to help consumers make better choices. He would require hospitals and providers to collect and publicly report cost and quality measures, including data on medical errors, staffing ratios, care disparities, and hospital-acquired infection. He would also require health plans to disclose the percentage of premiums that go directly to patient care, according to his plan, although the details have yet to be fleshed out.
He has also pledged to address skyrocketing malpractice costs by strengthening antitrust laws to prevent insurers from overcharging physicians.
Sen. Obama's advisors estimate the plan will cost between $50 and $65 billion a year when fully phased in, and they expect much of the money to come from savings in the system and the expiring tax cuts.
Sen. Obama's plan also notes the importance of addressing chronic care and issues such as HIV/AIDS, but does not attach a dollar figure.
THE REPUBLICAN POSITION
Sen. John McCain has not embraced universal health coverage but calls for increased access by providing tax credits to families — not employers — to purchase insurance.
Sen. McCain provided details of his plan for the first time in an April 29 speech in Tampa, FL. He called for eliminating the tax breaks that the government currently gives to employers who provide health insurance for their workers, and replacing them with $2,500 tax credits to individuals and $5,000 tax credits for families to buy their own insurance. The idea is to introduce more competition in the insurance industry, and thus drive down prices.
In that speech Sen. McCain also proposed that the federal government help states provide insurance coverage for sick, “high risk” people who can't get coverage on their own.
Sen. McCain does not address comparative effectiveness, and does not call for increased funding for existing government health programs or insurance reform on the scale that Sen. Obama does. But he does propose that veterans be able to take their benefits to any physician they choose.
Sen. McCain's plan calls for greater use of health savings accounts and increasing patients' responsibility for their own care, and promises to pass the medical liability reform bill that has languished in Congress for the last several years.
Like his Democratic rival, however, he proposes shifting provider payments to encourage better coordination of care among all providers to improve patient outcomes, more emphasis on diagnosis and prevention, cost and quality transparency, and improved technology.
Sen. McCain's campaign estimates the cost of his plan at about $7 billion annually.
HOW PHYSICIANS CAN MAKE A DIFFERENCE
The fact that the candidates agree on reforming the system by paying for quality improvements encourages the experts, although the specifics are still vague about how this would be accomplished.
“It's increasingly clear that you can't really do system reform without doing Medicare payment reform,” said Len Nichols, a health-care economist and director of the Health Policy Program at the New America Foundation, a nonprofit public policy institute.
“The lynchpin is realigning incentives,” Nichols said, in a way that doesn't hurt specialists like neurologists but includes more patients. That means paying more for providers to coordinate on the total health of patients and emphasizing payment for specific procedures less, he said.
The benefits of universal health care, as the Democrats propose, are likely more immediate for primary care physicians who see the most indigent cases, Nichols said, but neurologists would also benefit.
“They would be begged less to take complicated diagnostic processes for free or reduced cost,” he said.
“Both parties are talking about it [reform], and that's new, but physicians must be active in the process to ensure it comes out right,” Glen Finney, MD, assistant professor of neurology in the Memory and Cognitive Disorders Program at the University of Florida, told Neurology Today. Dr. Finney led a health policy seminar at the AAN annual meeting in Chicago in April.
“We have to engage the system,” he continued. “We have to be providing our own suggestions about quality care and what is practical to measure,” he said.
He added: “While we need to guarantee high-quality medical care, we need to safeguard that it is not instituted in a way that it either increases the workload for little return on that time investment or is transformed into a cost-cutting initiative that has little added value.”
Congress is also key. “We always have the hope that someone new in the White House can effect change, but unless we see movement in Congress… nothing gets done,” Dr. Finney said.
Dr. Finney encouraged neurologists to engage with the campaigns and Congress and offer suggestions on how to structure quality reforms.
“Right now what's being discussed are all process measures. We eventually have to develop outcome measures,” he said, adding that it is particularly difficult to do so for neurology because so much depends on the uniqueness of the patient.
“For neurology, there's a lot more research that needs to be done before anything can be instituted,” Dr. Finney said.
THE CANDIDATES' PLANS
Sen. Barack Obama:
* Establish a new public insurance program, available to Americans who neither qualify for Medicaid nor the State Children's Health Insurance Plan (SCHIP), nor have access to insurance through their employers, as well as to small businesses that want to offer health insurance to their employees
* Create a National Health Insurance Exchange to help Americans and businesses that want to purchase private health insurance directly
* Require all employers to contribute towards health coverage for their employees or towards the cost of the public plan
* Mandate all children have health care coverage
* Expand eligibility for the Medicaid and SCHIP programs
* Allow flexibility for state health reform plans
Sen. John McCain:
* Oppose mandates for coverage
* Provide a refundable tax credit of up to $2,500 (individuals) and $5,000 (families) to all individuals and families to purchase insurance
* Work with states to create a federally-supported Guaranteed Access Plan for people who are denied coverage due to pre-existing conditions; premiums in the plan would be limited and financial assistance given to those below a certain income level
* Give states flexibility to experiment with use of private insurance and per episode payments under Medicaid, and alternative forms of access, insurance policies and providers, and different licensing schemes for providers
* Allow re-importation of drugs, and encourage faster introduction of generics and biologics